Starting January 1, 2020, Medicare will only accept claims submitted with the Medicare Beneficiary Identifier (MBI). Medicare will reject any claims submitted with the Health Insurance Claim Number (HICN) with a few exceptions. Review the MLN Matters Article (PDF) to learn about getting and using the MBI.

Addressing Social Determinants of Health Will Help Achieve Health Equity

Social determinants of health can include housing, transportation, education, social isolation, and more. These factors affect access to care and health care utilization as well as outcomes. Organizations may measure these factors using a number of existing tools, including:

Z codes from ICD-10-CM: Group of codes within the ICD-10 (diagnostic) codes that help capture a patient’s socioeconomic and/or psychosocial needs
Accountable Health Communities Health-Related Social Needs Screening Tool: Identify needs related to social determinants
Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) Tool: - Opens in a new window : Collect the data needed to better understand and act on patients’ social determinants of health
Health Leads Screening Toolkit - Opens in a new window : Comprehensive way to assess patients for adverse social determinants

Data collection will help CMS strengthen our understanding of the relationship between social determinants of health and health care use across diverse populations, allowing us to develop solutions and better connect patients to much needed services. We are beginning this effort in several post-acute care provider settings this year by proposing that some data elements be collected on standardized patient assessment instruments.

In an effort to reduce expenditures and improve health outcomes, CMS is testing the Accountable Health Communities Model, which is the first model to include social determinants of health. The model is based on emerging evidence that shows addressing health-related social needs through enhanced clinical-community links can improve health outcomes and reduce costs.

For more information, visit the Office of Minority Health website. See the full text of this excerpted CMS Blog (issued April 26).

Clinical Diagnostic Laboratories: Resources about the Private Payor Rate-Based CLFS

The Protecting Access to Medicare Act of 2014 (PAMA) required significant changes to how Medicare pays for clinical diagnostic laboratory tests under the Clinical Laboratory Fee Schedule (CLFS). Effective January 1, 2018, the payment amount for most tests equals the weighted median of private payor rates. Payment rates under the private payor rate-based CLFS are updated every three years.

If you are a laboratory, including an independent laboratory, a physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory, you are required to report information, including laboratory test HCPCS codes, associated private payor rates, and volume data.

Learn more by reading:

Summary (PDF): Overview of key terms and concepts and how to determine whether your laboratory is an applicable laboratory
MLN Matters Article (PDF): Detailed information and examples to help you determine if you need to report
Frequently Asked Questions (PDF): Responses to questions regarding the changes effective January 1

If you meet the applicable laboratory criteria, act now using this schedule:

January – June, 2019: Collect data
July – December, 2019: Analyze data
January – March, 2020: Report data

For more information, review the from the January 22 Medicare Learning Network call and the PAMA Regulations webpage.

IRF, LTCH, and SNF Quality Reporting Programs: Submission Deadline May 15

The submission deadline for the Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) Quality Reporting Programs for the fourth quarter of 2018 is May 15.

For More Information:

IRF Quality Reporting Data Submission Deadlines webpage
LTCH Quality Reporting Data Submission Deadlines webpage
SNF Quality Reporting Program Data Submission Deadlines webpage

Medicare Promoting Interoperability Program: Submit a Measure Proposal by June 28

The Annual Call for Measures for eligible hospitals and critical access hospitals participating in the Medicare Promoting Interoperability Program is open. Submit a measure proposal by June 28. Proposals will be considered for inclusion in future rulemaking.

CMS is interested in adding measures that:

Build on the advanced use of certified electronic health record technology using 2015 edition certification standards and criteria
Promote interoperability and health information exchange
Improve program efficiency, effectiveness, and flexibility
Provide patient access to their health information
Reduce clinician burden
Align with the Merit-Based Incentive Payment System Promoting Interoperability performance category

Applicants should also consider:

Health IT activities that may be attested to in lieu of traditional reporting
Potential new opioid use disorder prevention and treatment related measures
Measurable outcomes demonstrating greater efficiency in costs or resource use that can be linked to the use of health IT-enabled processes

For More Information:

Nursing Home Compare Refresh

The April 2019 Nursing Home Compare refresh is available, including quality measure results based on Skilled Nursing Facility (SNF) Quality Reporting Program data. Visit the Nursing Home Compare website to view the data. For more information, visit the SNF Quality Public Reporting webpage.

Save Lives: Clean Your Hands

May 5 is Hand Hygiene Day - Opens in a new window , the World Health Organization’s annual call to action. Clean your hands at the right times and stop the spread of antibiotic resistance.

Medicare Learning Network resources:

Infection Control: Hand Hygiene - Opens in a new window Video: Learn when to wash your hands and techniques to wash visibly and non-visibly dirty hands — run time 1:58
Infection Control: Hand Hygiene - Opens in a new window Web-Based Training Course: Learn about hand hygiene in patient care zones and nearby administrative areas; appropriate methods for maintaining good hand hygiene; and how to recognize opportunities for hand hygiene in a health care setting — with continuing education credit

Compliance

Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities

In a recent report, the Office of the Inspector General (OIG) determined that Medicare inappropriately paid acute-care hospitals for outpatient services provided to beneficiaries who were inpatients of other facilities, including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. As a result, beneficiaries were unnecessarily charged outpatient deductibles and coinsurance payments.

All items and non-physician services provided during a Medicare Part A inpatient stay must be provided directly by the inpatient hospital or under arrangements with the inpatient hospital and another provider. Use the following resources to bill correctly:

MLN Matters Special Edition Article (PDF)
Provider Compliance Tips for Ordering Hospital Outpatient Services (PDF) Fact Sheet
Acute Care Hospital Inpatient Prospective Payment System (PDF) Fact Sheet: See payment information on page 3
Items and Services Not Covered Under Medicare (PDF) Booklet, Page 12
Medicare Claims Processing Manual, Chapter 3 (PDF), Section 10.4
Medicare Inappropriately Paid Acute-Care Hospitals for Outpatient Services They Provided To Beneficiaries Who Were Inpatients of Other Facilities OIG Report, September 2017

Events

DMEPOS Competitive Bidding Webcast Series: Get Ready for Round 2021

CMS is launching a series of three webcasts to educate on key components of the Durable Medical Equipment, Prosthetic, Orthotics, and Supplies (DMEPOS) Round 2021 bidding process. All webcasts are from 3 to 4 pm ET:

May 14 – Bid Surety Bond and Lead Item Pricing
May 21 – Preparing and Submitting Financial Documents
May 28 – Registering and Submitting a Bid

Register - Opens in a new window for the Bid Surety Bond and Lead Item Pricing webcast. Registration for the other two webcasts will be provided at a later date.

Questions may be submitted during the webcast, or in advance to with “Webcast Question” in the subject line. Questions do not need to be limited to the topics included in the webcast, but should pertain to Round 2021. We look forward to your participation.

CMS Primary Cares Initiative: Direct Contracting Model Webcast — May 7

Tuesday, May 7 from 3 to 4 pm ET

The CMS Primary Cares Initiative is a new set of payment models that will transform primary care to deliver better value for patients throughout the health care system. Direct Contracting is a set of three voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service. These payment model options create opportunities for a broad range of organizations. During this informational session, learn about requirements, benefits of participation, and application process.

Quality Payment Program: Advanced APMs Webinar — May 9

Thursday, May 9 from 2 to 3 pm ET

During this webinar, learn about Advanced Alternative Payment Models (APMs)—one of the two tracks of the Quality Payment Program. Topics include:

Criteria for Advanced APMs in 2019 (Year 3)
Qualifying APM Participant status
Resources and technical assistance

CMS Primary Cares Initiative: Primary Care First Model Webcast — May 16

Thursday, May 16

Register for a webcast from 12 to 1 pm ET - Opens in a new window or 3 to 4 pm ET - Opens in a new window ; both sessions present the same information.

The CMS Primary Cares Initiative is a new set of payment models that will transform primary care to deliver better value for patients throughout the health care system. The Primary Care First payment model options will test whether financial risk and performance-based payments that reward primary care practitioners and other clinicians are easily understood, have actionable outcomes that reduce total Medicare expenditures, preserve or enhance quality of care, and improve patient health outcomes. During this information session, learn about requirements, benefits of participation, and application process.

MLN Matters® Articles

ESRD PPS: Quarterly Update

A new MLN Matters Article MM11215 on Quarterly Update to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) (PDF) is available. Learn about a new HCPCS code for anemia management.

Publications

Medicare Billing: CMS Form CMS-1450 and the 837 Institutional — Reminder

The Medicare Learning Network Booklet is available. Learn:

When Medicare will accept a hard copy claim form
Filing requirements
How to submit and code claims

Medicare Billing: CMS Form CMS-1500 and the 837 Professional — Reminder

The Medicare Learning Network Booklet is available. Learn:

When Medicare will accept a hard copy claim form
Filing requirements
How to submit and code claims

Multimedia

Opioid Video

A video presentation - Opens in a new window is available for the Medicare Learning Network call on the New Part D Opioid Overutilization Policies. Learn about the new policies effective January 1.

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